Problems with Pain

Background

Though pain is traditionally thought of as the bodily awareness to harmful or noxious stimuli, the subject of pain has far more depth than one might initially believe. The issues surrounding pain, pain philosophy, and pain management are far-reaching and are replete with ethical and moral conundrums.

One of the most pertinent issues relating to pain is how it should be managed. For physicians treating patients who suffer from chronic pain, choice of pain management strategy can have distinct costs and benefits. The dilemma presents itself most distinctly in the case of opiates like morphine and codeine, which, while having the greatest analgesic potential, also have the greatest risk of addiction. On the other hand, approaches with no potential for addiction, such as Paracetamol, NSAIDs, and cognitive therapies, have weak analgesic qualities in comparison with opiates. COX-2 inhibitors, like Vioxx, are quite effective analgesics, but can increase the risk of adverse cardiovascular events. Just as pain has the potential to be life-style altering, so do the treatments, thus doctors must weigh the effect of the pain on the patient against the possibility of physical dependence or heart attack, which are also life altering. Treatment of pain is complicated further by multiple factors: first, pain is a symptom that can affect one’s quality of life directly; second, pain can present itself with few physiological correlates; third, there is no way for a doctor to objectively and quantitatively measure the pain of a patient.

Pain assessment is currently inaccurate, subjective, and inconsistent; however, there is no evidence that it could shed any of these qualities in the near future. As the “How real is your pain?” (Haig, 2007) shows, much of how one feels pain depends on the bio-psycho-social model, in that the pain a patient is actually feeling is inseparable from their mental state at the time. As a result, doctors use measures of pain such as the VAS (visual analog pain scale) in which patient self quantify their pain. Though there have been many attempts at objectively measuring pain, such as measuring brain waves as seen in the article, “Brain waves reveal intensity of pain” by Kerri Smith. However, other characteristics of pain beyond intensity are exceedingly difficult to characterize, let alone interpret. Pain is a multifaceted sensation, with wide variation in many aspects, including area (large vs. small), type (burning, stabbing, aching, etc.), and periodicity (constant vs. in intervals). Beyond these it also exists in two dimensions: spatial and temporal, otherwise known as, “Where does it hurt?” and “How long does it last?” Doctors try to gain referential information based on the pain response to stimuli like a poke, or walking, but really, as the Haig points out, “the mind remains our most important machine in medicine” in terms of gauging pain in others.

This too runs into a quagmire, best described by an analogy created by Wittgenstein, called Wittgenstein’s Beetle. It describes a society in which everyone has a box with a beetle in it, but they are only allowed to look in their box, though they can describe the contents of their box to others. Over time, everyone begins to assume that their beetle has the same qualities of everyone else’s beetle, but there is no way for them to know with any certainty, as they cannot directly observe other beetles. In this case, the beetle is a stand in for “mind,” in that one cannot directly observe the mental facilities and experience others though generally assumed that everyone has a mind, and that they all function the same way., Thus one must rely on their descriptions to understand their mental functioning. This is a key problem in pain treatment, as a doctor cannot completely understand the pain a patient is experiencing, thus must rely on their own judgments to determine treatment.

Central Questions

• How can one separate pain with a physical correlate from pain that is psychosomatic?
• How can one understand the pain another is in, and use this as a basis of treatment?
• Can pain be measured objectively? Is measuring pain objectively more effective than subjectively?

Summary/Reflections

The validity of treating pain with acupuncture, which is not a traditional allopathic approach, had been called into question due to its susceptibility to naloxone blocking, which also blocks the placebo effect. This would then support the case that acupuncture is a treatment that works psychosomatically, owing to the psychosomatic nature of the pain itself. However, a counter argument was presented in which anecdotal evidence supporting the efficacy of acupuncture, namely its veterinary applications in the treatment of pain in dogs. As dogs are not aware of the expected outcome of the acupuncture, they would not be subject to the placebo effect, potentially validating a physiological basis for acupuncture. Additionally, it is common practice for modern acupuncturists to give modern explanations as to why their treatment works; however, the question was brought up that if an acupuncturist gave a traditional explanation as to why their treatment worked, would people still respond? Perhaps one should not so rapidly dismiss traditional treatments for pain, as there could be some scientific basis behind why these treatments, such as acupuncture, have remained relevant for thousands of years.

The experiential nature of pain was discussed, with particular emphasis on how socio-psychological factors could affect their self-rating of pain. The example was discussed of Jacob, a man described in the “How real is your pain?” article, who rates his pain as a “one” (lowest) on the VAS scale, despite having a horribly broken arm. He was then used as a point of contention as to whether his apparent lack of pain was due to social and emotional differences or neural differences. A synthesis was given that it is a combination of all of these that lead to altered pain perceptions; in the case of Jacob, social cues might tell him he should not be expressive about the pain he is in, but this top-down control of his mental state might actually cause neural state changes, such as the release of endogenous opioids, which might change the way he is feeling the pain. This could be the case with those who feel pain differently when it is socially acceptable versus when it is not acceptable, for example, an injured football player should feel less pain than a woman giving birth. This can be attributed to the notion that one is supposed to be “a trooper” and shrug off sports injuries, while giving birth is universally recognized and accepted as extremely painful.

Factors such as these make measuring pain in patients much more complicated. As per the beetle analogy, a doctor cannot completely know the pain his or her patient is experiencing, and thus must rely on observation, patient input, and intuition. However, in the medical world there is a constant push to remove responsibility from the caregiver and place it on a device that can be objective. It is because of this drive are their attempts to quantify pain with devices such as brain wave monitoring. Approaches such as these have issues in order to work completely accurately, as one would have to measure brainwaves at a baseline level in advance. Also, these normalize the baseline level; they do not account for the idea that baseline might be variable from person to person. Sometimes, it seems, the best way to account for the variability from mind to mind is to account for it by allowing subjective assessment by a doctor following observation.

Future Directions

By studying how pain has developed historically, insight might be gained into how one’s social and cultural environment affects their symptoms of pain. The basis for this comes from the perceived shifting of aesthetic values as seen in "Spinal Irritation" and Fibromyalgia: A Surgeon General and the Three Graces” (Weissmann, 2008). The shifting body types of the three graces are indicative of the changing socio-cultural expectations of the female form; potentially linked to changes in rate of “spinal irritation.” Perhaps what should be considered for future pain research is not to examine the biological underpinnings of pain, but rather to examine the socio-cultural correlates which might have a role in generating the pain.

References

Haig, Scott. "How Real is Your Pain?" TIME 20 Feb. 2007. 2 May 2008 <http://www.time.com/time/health/article/0,8599,1591681,00.html>.

Smith, Kerri. "Brain Waves Reveal Intensity of Pain." Nature 14 Nov. 2007. 2 May 2008 <http://www.nature.com/news/2007/071114/full/450329b.html>.

Weissmann, Gerald. "“Spinal Irritation” and Fibromyalgia:." FASEB 22 (2008): 327-331. 2 May 2008 <http://www.fasebj.org/cgi/reprint/22/2/327>.